MEDICARE: UNRAVEL AWARENESS PSYCHOTHERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1861253288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNRAVEL AWARENESS PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	9025 NE SACRAMENTO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-5458
Country	:	US
Telephone Number	:	971-373-7728
Fax Number	:

Provider Business Practice Location Address
First Line	:	9025 NE SACRAMENTO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-5458
Country	:	US
Telephone Number	:	971-373-7728
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL SOCIAL WORKER
Name	:	RHEN MILES
Credential	:	LCSW
Telephone Number	:	971-373-7728

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	01/22/2024

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